Free CHSP Compliance and Accreditation Questions and Answers

Question 1

A hospital is seeking accreditation from an organization that uniquely integrates ISO 9001 quality management principles with its standards and conducts annual on-site surveys.
Which accrediting body would the hospital be engaging with?

Accepted Answer

DNV (Det Norske Veritas)

Answer

The Joint Commission (TJC)

Answer

Centers for Medicare & Medicaid Services (CMS)

Answer

Occupational Safety and Health Administration (OSHA)

Question 2

As part of its emergency management program, a hospital is reviewing the CMS Conditions of Participation (CoP) for Emergency Preparedness. Which of the following is a core element required by this rule?

Accepted Answer

Developing a communication plan to coordinate patient care with other providers and emergency systems.

Answer

Conducting a community-based disaster drill at least once every five years.

Answer

Limiting emergency training to clinical staff and first responders only.

Answer

Mandating that the emergency plan be approved by the Federal Emergency Management Agency (FEMA).

Question 3

A safety professional is auditing compliance with The Joint Commission's National Patient Safety Goals (NPSGs). Which of the following initiatives directly addresses a 2025 NPSG?

Accepted Answer

Implementing a new process for reducing the risk of healthcare-associated infections.

Answer

Reducing overhead pages to create a quieter hospital environment.

Answer

Offering expanded meal options on the patient menu.

Answer

Upgrading the hospital's parking garage lighting system.

Question 4

According to the NFPA 101, Life Safety Code®, what is the primary determinant for classifying a facility as a 'Health Care Occupancy' versus an 'Ambulatory Health Care Occupancy'?

Accepted Answer

Whether four or more patients are treated on an inpatient basis.

Answer

The number of operating rooms in the facility.

Answer

The total square footage of the building.

Answer

The presence of a 24-hour emergency department.

Question 5

A healthcare facility is cited by OSHA for a violation of the 'General Duty Clause'. Which of the following scenarios would MOST likely lead to such a citation?

Accepted Answer

Lacking a program to address the recognized hazard of workplace violence.

Answer

Failing to provide annual bloodborne pathogen training to all employees.

Answer

Not having a written Hazard Communication plan available for review.

Answer

Improperly labeling a secondary container of a cleaning chemical.

Question 6

A hospital surveyor is assessing compliance with The Joint Commission's Universal Protocol for preventing mistakes in surgery. Which of the following is a required step in this protocol?

Accepted Answer

Performing a 'time-out' immediately before starting the procedure.

Answer

Ensuring the patient's family members agree with the procedure.

Answer

Conducting a post-procedure debrief with the surgical team.

Answer

Videotaping the entire surgical procedure for quality review.